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Mentally Ill and Still Without Health Insurance

Nearly 4 million seriously mentally ill people in America are still without insurance.

Some might consider Kelly Troyer of South Carolina lucky. She isn’t one of them.

Thanks to the generosity of her church and family members, she receives some treatment for the depression and post-traumatic stress disorder she suffers as a result of the sexual assault she endured in 2012. But Troyer, 45, said her lack of health insurance and other uncovered medical costs, including a hospitalization and all her medications, has forced her into personal bankruptcy.

She lives in one of the 24 states that chose not to expand their Medicaid programs, offered under the Affordable Care Act. Those decisions have left about 3.7 million Americans with serious mental illness, psychological distress or a substance abuse disorder without health insurance, according to a recent report from the American Mental Health Counselors Association (AMHCA), a group that represents mental health professionals.

In states that agreed to expand Medicaid, about 3 million people who have those conditions and were uninsured are now eligible for coverage, according to the report.

“It makes no sense that this state would not accept the Affordable Care Act,” Troyer said. “Don’t say no and then don’t offer another option. There are people who are homeless now because they don’t have health insurance. I could be one of them.”

Option Offered

Medicaid, the federal-state health care program for the poor, is the primary means by which states pay for mental health care for the poor. Medicaid beneficiaries are entitled to comprehensive care for mental illness and substance abuse.

Originally, the federal health care law enacted in 2010 required all states to expand Medicaid benefits to adults with annual incomes below 138 percent of poverty or $15,521 for an individual in 2014.

A 2012 U.S. Supreme Court decision gave states the option of notparticipating in the eligibility expansion. Most, but not all, states with Republican governors or Republican-controlled legislatures opted out, even though the federal government is paying 100 percent of the costs of the expansion in the first three years before tapering down to 90 percent after 2019.

The federal health law could have added as many as 18.7 million more Americans to the Medicaid rolls. With only 26 states now participating, that number is down to about 8.1 million. If the 24 states that opted out of the Medicaid expansion continue to do so, they will forgo a total of $61.9 billion in federal revenues by 2022, according to a December Commonwealth Fund report. Governors in those states say they don’t trust the federal government to come up with the promised money and worry the states will be left having to make up the difference.

“It is really a tragedy,” said Joel Miller, executive director of AMHCA. “When uninsured people with mental health conditions, such as depression, gain Medicaid coverage, they become healthier and life expectancy increases, but in states that refuse to expand Medicaid, citizens will see their hopes dashed for a better life and better health.”

The report gives state-by-state numbers of people with serious mental illness or substance abuse disorders who would have received Medicaid if their states had opted in to Medicaid expansion. The report covers 25 states, although since it was published, one of them, New Hampshire, decided to reverse course and join the expansion states.

Funding Cuts

Separate from Medicaid, many states have also funded community mental health programs, but they have also sharply reduced spending on those programs in recent years. The National Association of State Mental Health Program Directors estimated that in the four years ending in 2012, states reduced mental health spending by a total of $4.35 billion.

Because of those reductions, mental health advocates have pressed hard for states to expand Medicaid eligibility. “Medicaid expansion is the single most important thing our leadership could do for people with mental illness,” said Greg Hansch, policy coordinator of the National Alliance on Mental Illness in Texas, which decided not to expand and left 652,000 low-income severely mentally ill Texans without coverage, according to the AMHCA report.

The situation is similar in Kansas, which AMHCA said has 52,000 uninsured people with severe mental illness. According to state Rep. James Ward, a Democrat, the state has cut its spending for community mental health by more than 50 percent since 2007.

Medicaid expansion would have helped address the state’s mental health needs, he said. Instead, he expects the situation will go from bad to catastrophic with “more people falling through the cracks, more of the mentally ill jailed, more homeless, all of the effects you have when there isn’t mental health treatment.” As it is, Ward said, the largest mental health ward in his home county of Sedgwick is the jail.

Ward expressed frustration that despite episodes such as the recent fatal shooting at Fort Hood in Texas that focused attention on deficiencies in mental health treatment, Republicans in his state have blocked Medicaid expansion. Nearly eight in 10 of all uninsured people with either a mental health condition or substance abuse disorder live in one of the 11 Southern states that didn’t expand Medicaid, the AMHCA report said. (The report includes Texas and Oklahoma in those states.)

The reason for that concentration, said Miller, the association’s director, is that these states generally had the most restrictive Medicaid eligibility requirements before the federal health law was enacted.

Indiana Ranks Highest

Of the states that didn’t expand, Indiana had the highest percentage of adults with mental health conditions among those who would have been Medicaid-eligible – 62 percent. Georgia had the lowest at 27 percent, the report found.

The primary source of information for the AMHCA report was the National Survey on Drug Use and Health cosponsored by the Substance Abuse and Mental Health Services Administration in the U.S. Department of Health and Human Services and the U.S. Census Bureau’s American Community Survey.

The survey counted people in three categories of mental illness: those with serious mental illness, meaning that they had a diagnosable mental, behavioral or emotional disorder that had resulted in serious functional impairment; serious psychological distress with frequent intense feelings of nervousness, hopelessness, restlessness, worthlessness or sadness; and substance abuse disorder, meaning abuse or dependence on illicit drugs or alcohol.

Those criteria were derived from “Diagnostic and Statistical Manual of Mental Disorders,” published by the American Psychiatric Association, which is used by most mental health care providers, health insurers and pharmaceutical companies.

Whether Kelly Troyer, who worked in nonprofits until the assault, is one of the 192,000 South Carolinians without coverage that the AMHCA report cited, she doesn’t know. What she does know is that she hasn’t been able to work. “There’s a stigma that it’s people’s fault that they’re not working,” she said. “It’s frowned upon that you need help instead of looking at it like this is the right thing to do to give everyone access to care.”

She half seriously noted that if it weren’t for the help she gets from her church and family, she might have been better off in prison. “Prisoners in the Greenville County Detention Center have better mental health care than I can get out here.”